What is the best procedure for marionette lines?

Question

I am 45, and a few years ago I noticed marionette lines and now they are getting more noticeable. I have had Artefill injected a few years ago and noticed very little change. I also had Juvederm Ultra injected more recently and noticed hardly any change. I am hoping a lower face lift with fat transfer to the lines will make a more dramatic change. What is actually the best procedure for my problem?

Raymond E. Lee, MD · Answer

Thanks for posting your question as it is a common one.  Marionette lines or the wrinkle/folds from around the mouth to the chin can initially be treated with fillers or fat in a younger patient with adequate elasticity.  However, when there is enough aging, simply placing filler product here has a limit and will have limited change or even an unnatural result when too much product is placed. (I will add, laser resurfacing and radio frequency also have a limited role to help here too in the younger patient).  The next step would be to consider a lower facelift.  A lower facelift really improves the marionette lines/folds, jowls, and neck.  Incisions may vary depending on each patient's aging.  After lifting, fillers or fat may not be desired or on the contrary may even work better to help to further efface lines and folds for additional result.  Please consult with several board certified surgeons experienced in facial rejuvenation to review all your options.

Jason Emer, MD · Answer

I recommend fillers to soften the nasolabial folds themselves and also lift around the mouth and cheeks to build underlying anatomical support. In our practice we combine Sculptra with other fillers "layered" on top and lasers, skin tightening treatments such as Thermage, Fractora, and Renuvion (J Plasma), thread lifting,  and peels to get the most conservative, natural look. I suggest seeing a facial sculpting expert for a formal consultation. Best, Dr. Emer

Alejandro J. Quiroz, MD · Answer

Thank you for your question. The best treatment for the marionette lines is totally individual to the given individual. Some times a filler or a combination with botox or surgery is there is overhanging skin or combination

Ali Riza Öreroglu, MD · Answer

I would definitely include some volumizing procedure (fillers or fat) to correct your midface and lower face deficiency. A midface lift would also be beneficial to correct the nasolabials and Marionettes; since the periorbital deformities can be assessed through the same approach.
In addition, for patients who do not want surgery, fillers in addition to skin tightening procedures (such as needle RF) give good results specially when it comes to younger patients.
My best option however would be a lower facelift (composite) combined with fat injections. This is one of the most effective and long lasting procedure that you can have.
Hope this helps,
Ali Rıza Öreroğlu, MD FEBOPRASEuropean and Turkish Board Certified Aesthetic, Plastic and Reconstructive SurgeonIstanbul, Turkey

J. Jason Wendel, MD, FACS · Answer

Thank you for your question about lower face lift.If fillers have failed, then yes, a lower face lift, fat transfer and/or laser resurfacing might be beneficial for you.To be sure, see two or more experienced, board-certified Plastic Surgeons for a complete evaluation to make sure you are a good candidate and that it is safe for you to have surgery.I hope this helps.

Timothy R. Miller, MD · Answer

Depends.There is no one answer for marionette lines.  The best recommendations would come after an evaluation of photographs or better yet during an in-office examination.The treatments, of course, vary depending on your anatomy and expectations.  Choices include syringe based fillers like Juvederm or Voluma, or can be more comprehensive to include fat transfer.  Lower facelift techniques can improve most marionette lines but to thoroughly reduce the lines a filler or fat should be used in combination; that is, you can not typically "lift" a marionette line 100% smooth (long-term) without looking pulled or altered. The attached link provides more information.I hope this helps.

Dilip D. Madnani, MD, FACS · Answer

Great question and one I hear a lot. Fillers and other treatments that are considered minimally invasive or noninvasive are excellent up to a point. They usually address one of the aspects of aging- whether its volume loss or facial lines. The other culprit in aging has to do with excess skin- you sound like you are at the point of needing something to treat your skin excess. Adding fillers to the marionette area when excess skin is involved, will not show much of a result, and if the patient or injector feels that not enough filler was injected, so more is placed into the marionette area- this will lead to a jowly appearance, which may improve the marionette lines but leads to another problem- large jowls.A face and neck lift (the type of facelift will be determined on your physical examination) with a fat transfer will be your best option with the most long term and natural results. It will give you the youthful rejuvenation you are looking for without having to return for fillers on a regular basis. Please view my gallery and my website for examples of face and neck lifts/Minilifts/lower facelifts with fat transfer to see what you can expect. Good luck!

Toby Mayer, MD · Answer

The best treatment for sagging skin and marionette lines based on 35 years experience is a facelift and Voluma. Fat transfer is great for hands and lips but not for marionette lines. It will give poor results or lumps since the skin is firmly bound to the muscla.

Roger Allcroft, MD · Answer

A cheek neck lift would most likely give the most improvement. An injectable filler is still often needed for an optimal result. since you didn't see improvement with Juvederm I would try a filler that can raise up tissue better such as Perlane.

Robert Singer, MD · Answer

There are a number of surgical and
non-surgical options that can improve one's cosmetic appearance: fillers,
skin-tightening procedures, lasers, fat contouring, neck and face lifts. Each
has benefits and drawbacks. Mini procedures do not produce the long lasting
maximum improvement that is achieved with a natural appearing artistically
performed lift performed by an expert experienced plastic surgeon. That is
achieved by a combination of elevating the sagging tissues, removing the excess
skin, contouring the fat, and adding micro-fat grafts or fillers where there is
a deficiency.The best option need to be individualized for each person and depends on their particular anatomy and desired outcome.Keep in mind, that following the exact
advice from a surgeon on this or any other website who proposes to tell you exactly
what to do without seeing photos and more importantly without examining you,
physically feeling the tissue, assessing your desired outcome, taking a full
medical history, and discussing the pros and cons of the proposed operative
procedure may not be in your best interest. I would suggest you find a plastic
surgeon certified by the American Board of Plastic Surgery and ideally a member
of the American Society for Aesthetic Plastic Surgery (ASAPS) that you trust and are comfortable with. You should discuss your concerns with that surgeon in person. Robert Singer, MD FACS La Jolla, California